A Comparison of Pain Scales in Patients with Disorders of Consciousness Following Craniotomy.

OBJECTIVE: Evaluate the validity, reliability, and practicality of pain assessment tools in patients with disorders of consciousness who underwent craniotomy. MATERIAL AND METHOD: This prospective observational study cross-validated three pain scales, FLACC (Face, Legs, Activity, Cry, Consolability), rFLACC (Revised FLA CC), and NCS (Nociception Coma Scale), based on validity, reliability, and practicality. After translation, the three pain scales were tested for concurrent validity, construct validity, and interrater reliability in patients who experienced disorders of consciousness within 24 hours following craniotomy. Opinions regarding practicality were elicited via questionnaire from nurses who have used and are familiar with these pain scales. RESULTS: Fifty-eight patients were enrolled in the present study. Concurrent validity was supported by positive correlations among all scales, which ranged from r = 0.638 to r = 0.978. All scales yielded fair to moderate agreement (K = 0.380-0.626) with routine clinical decision to treat postoperative pain. Concurrent validity was much improved in the assessment of intubated patients. Construct validity was demonstrated by high scores (3-5) in higher pain situations before analgesic was given and low pain scores (0) in pain-free situations after analgesic was given. All scales had good interrater reliability (intraclass correlation = 0.7506-0.8810). CONCLUSION: All pain scales were found to be valid and reliable, especially in intubated patients. In terms ofpracticality, NCS was found to be the most acceptable by practitioners.

Predictors of physical functioning in postoperative brain tumor patients.

A cross-sectional predictive design was used to study the relationships among recovery symptoms, mood state, and physical functioning and to identify predictors of physical functioning in patients who underwent surgery for brain tumor at the first follow-up visit (2 weeks) after hospital discharge. The sample included 88 patients who were 18 years or older, had full level of consciousness, and underwent first-time surgery for brain tumor without other adjuvant treatments from a tertiary hospital in Bangkok, Thailand. Descriptive statistics, Pearson product-moment correlation coefficient, and multiple regression were used for data analysis. The results revealed that most participants were women (75%) with an average age of 45.18 ± 11.49 years, having benign brain tumors (91%) and pathological results as meningioma (48.9%). The most common recovery symptoms were pain (mean = 3.2, SD = 2.6) and sleep disturbance (mean = 3.1, SD = 3.0). As for mood state, the problem of confusion was found the most (mean = 4.6, SD = 2.7). The physical functioning problem found the most was work aspect (mean = 66.3, SD = 13.3). Recovery symptoms had positive relationships with physical functioning and mood state (r = .406, .716; p < .01), respectively. At the same time, mood state had positive relationships with physical functioning (r = .288, p < .01). Recovery symptoms, total mood disturbance, fatigue, and vigor were statistically significant predictors of physical functioning and could explain variance of postoperative physical functioning in these patients at 2 weeks after discharge by 35%. Total mood disturbance was the strongest predictor of physical functioning followed by vigor, fatigue, and recovery symptom, respectively. Interventions to improve physical functioning in postoperative brain tumor patients during home recovery should account for not only recovery symptom management but also mood state.

Socioeconomic Trends in Deep Brain Stimulation (DBS) Surgery.

OBJECTIVE: We evaluated trends in deep brain stimulation (DBS) for the 14-year period from 1993 to 2006. MATERIALS AND METHODS: We utilized the Nationwide Inpatient Sample data base from the Healthcare Cost and Utilization Project, Agency for Healthcare Research and Quality. RESULTS: A total of 34,792 patients underwent DBS surgery from 1993 to 2006. There were 756 DBS cases performed in 1993 compared with 4200 DBS procedures performed in 2006. Significant increases in nationwide DBS volume coincided with regulatory approval for new indications-Parkinson's disease and dystonia, respectively. Cost of DBS surgery increased from $38,840 in 1993 to $69,329 in 2006. The majority of cases were done in metropolitan areas (97%) at large academic centers (91%) at a national bill of $291 MM. CONCLUSIONS: Future studies will need to include the socioeconomic impact of the technology on disease status, patient access, and costs as it expands to novel indications.

Both thalamic and pallidal deep brain stimulation for myoclonic dystonia.

Myoclonic dystonia is poorly managed with medication and may be severe enough to warrant surgical intervention. Surgery has targeted either the globus pallidus pars interna (GPi) or the thalamus, but there is no accepted target for this condition. The authors present the case of a 23-year-old man treated with unilateral deep brain stimulation in both the thalamus and GPi. His movement disorder improved dramatically with stimulation. Two years postoperatively, the authors performed a double-blind assessment of the effects of each stimulator together, separately, and off stimulation. Videotape assessment, using tremor, dystonia, and myoclonus rating scales, showed that most of the benefit could be attributed to pallidal stimulation, although there was some advantage to stimulation at both sites. These results suggest that while GPi stimulation may be the better target for this condition, thalamic stimulation may be added in cases in which the benefit is insufficient.